Research on implementation of collaborative services the Australian experience

Transcription

1 Research on implementation of collaborative services the Australian experience Dr Alison Roberts Director Policy and Practice Pharmaceutical Society of Australia 8 th PCNE Working Conference 6-8 February 2013 Berlin, Germany

2

3 Community Pharmacy Agreements (CPA) Five-year agreements since signed between the Pharmacy Guild of Australia and the Federal Government Increasing shift towards and funding for professional services 2CPA CPA CPA CPA AU$ 4 M: Residential medication management reviews AU $300M : Medication reviews Consumer information AU $500M : Medication mgt Diabetes/ Asthma disease mgt (pilot) AU $660 M : Medication mgt Clinical interventions Primary health care 3

4 Collaborative medication reviews Research to policy Chen, TF et al. Medication regimen reviews a collaboration between community pharmacists and general medical practitioners. [Research report] 1999 Chen, TF et al. Collaboration between community pharmacists and GPs - the medication review process. J Soc Admin Pharm 16(3/4): Krass, I & Smith, C. Impact of medication regimen reviews performed by community pharmacists for ambulatory patients through liaison with general medical practitioners.int J Pharm Pract 8(2): Bennet A. et al. A comparative study of two collaborative models for the provision of DMMR. [Research report] 2000 Roberts, MS & Woodward, M. The domiciliary medication review project. [Research report] 2000 Gilbert, A and Beilby, J. Quality use of medicines in the community implementation trial. [Research report] : Policy uptake Home medicines reviews(hmrs) are a Government-funded service as part of the 3 rd Community Pharmacy Agreement

5 Research on HMR implementation Qualitative study (36 interviews owners, pharmacists, pharmacy assistants) 1 Thematic content analysis with NVivo software for data management Quantitative study (735 pharmacies, 1303 individual respondents) 2 Facilitators scale Factor analysis HMR data Descriptive statistics 1. Roberts AS, et al. Understanding practice change in community pharmacy: A qualitative study in Australia. Res Soc Admin Pharm 2005; 1(4): Roberts AS, et al. Practice change in community pharmacy: quantification of facilitators. Ann Pharmacother 2008; 42(6):

6 No. of pharmacies 300 Distribution of pharmacies (n=575) according to average number of HMRs conducted per month or more

7 Models of practice Position of person conducting HMRs Combination of internal pharmacists and external consultants 3.8% Missing data 4.0% Owner pharmacist/s 18.8% Employee pharmacist/s (full and part-time) 19.7% External consultant pharmacist/s 53.7%

8 Implications of this model 3 Lack of integration ( arms-length approach) Lack of interaction with GPs and patients Will not build loyalty Less financially viable Important implications for future services e.g. Disease state management 3. Roberts, A.S., et al., Implementation of Home Medicines Review (HMR) in community pharmacy. Aust Pharm, (10): p

9 In community pharmacy... services cannot just be added as the next retail category...everything from philosophy of practice and vision, to customer service and staffing, will need to be built from the ground up...a new approach, developing understanding of the service business model, is urgently required. 9

10 Implementation research Policy to practice? 2003 Benrimoj SI et al. An investigation into business and professional facilitators for change for the pharmacy profession in light of the Third Guild/Governme nt Agreement [Research report] 2004 Benrimoj SI et al. Quantification of facilitators to accelerate uptake of cognitive pharmaceutical services (CPS) in community pharmacy. [Research report] 2004 Dunphy D et al. Change management and community pharmacy [Research report] 2006 Roberts AS et al. Implementing cognitive services in community pharmacy: a review of models and frameworks for change. Int J Pharm Pract, (2): p Roberts AS et al. Community pharmacy: Strategic change management. Sydney: McGraw- Hill. [Book] 2009 Feletto EL et al. Building organisational flexibility to promote the implementation of primary care services in community pharmacy. [Research report] 2005: Policy uptake change management concepts incorporated into all professional programs and services in the 4th Community Pharmacy Agreement 10

11 Change management Change is hard, and generally more complex than first anticipated Often there is disagreement on how change should occur, between the policy level and the practitioner level: the point of view of those who think they are creating change as an intentional process will be different from those who are on the receiving end 4 4. Kanter, R.M., B.A. Stein, and T.D. Jick, The challenge of organizational change: how companies experience it and leaders guide it. 1992, New York: The Free Press

12 In reality 4CPA programs experienced: high rates of uptake/sign-up for programs low rates of maintenance or sustaining new services The funded change management program was subject to significant political disagreement on approach and was only rolled out in the final 6 months of the 5 year Agreement There was no overarching plan for rollout of programs and consideration of how projects and programs interrelate and how this might be better managed from the perspective of pharmacists participating in the programs 5 5. KPMG (2010). Review of the Professional Programs and Services Advisory Committee. Final report to the Department of Health and Ageing

13 Strategy based on flawed assumptions Professional program signup incentives Service payments, QCPP, IT support Sustained delivery of professional services to consumers 13

14 Impact of incentives Incentives do not alter the attitudes that underlie our behaviors. They do not create an enduring commitment to any value or action. Rather, incentives merely and temporarily change what we do. 6 The essential challenge is to ensure that incentives, structures and operations at the systems, organisational and practitioner level are consistent with each other and aligned in a way that supports the desired practitioner behaviour 7 6. Kohn, A (1993) Why incentive plans cannot work. Harvard Business Review 7. Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F(2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network

15 5 th Community Pharmacy Agreement $663 million in funding for programs to deliver professional services, including: Medication management Pharmacy Practice Incentive and Accreditation Program Aboriginal and Torres Strait Islander Programs Rural programs R&D Medication continuance Additional programs to support patient services

16 Medication management programs Existing programs: Home Medicines Review ($52.11M) RMMR ($70M) New programs: MedsCheck ($29.6M) Diabetes MedsCheck ($12.2 M) Meds Check is an in-pharmacy review of a patient s medicines, focusing on education and self management and aims to: Identify problems that the patient may be experiencing with their medicines; Help the patient learn more about their medicines including how medicines affect medical conditions; Improve the effective use of medicines by patients; and Educate patients about how to best use and store their medicines.

17 Pharmacy Practice Incentives (PPI) Funding of $344 million is provided for the PPI Program Initial eligibility requirements for all PPIs

18 Implementation strategy in 5CPA Example: MedsCheck Program Patient eligibility criteria Guidelines for service delivery Forms and claiming Detect Deliver Document Proactive or opportunistic? How many patients to target? Who is responsible for identifying and approaching patients? Where: private room or counselling desk? When: appointment system? Who: pharmacist availability, must not be dispensing When: at time of consult or after? Who is responsible for this task and any follow-up? Where will it be performed? Back office or counselling desk??

19 Implementation of programs and practices should not be viewed as plug and play where, somehow, new practices can be successfully added to ongoing operations without impacting those operations in any significant way. Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F(2005). implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network

20 Many of the common techniques do not work Successful implementation is not achieved by any of the following 8-10 : Dissemination of information (literature, mailings, guidelines) by itself Training alone, no matter how well done Laws/compliance by itself Following the money by itself Making no changes to supporting roles and functions 8. Schroeder, J.A (2011). Integrating implementation science, practice and policy. National Implementation Research Network 9. Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F(2005). Implementation Research: A Synthesis of the Literature. National Implementation Research Network 10. Nutt, P (2002). Why decisions fail.

21 A new approach is needed We need to challenge our practices and beliefs if things are to change Just because a program or service has been shown to have good outcomes for patients does not mean it will be easy to implement in practice Implementation scientists have shown that the usability of a program or practice has little to do with the weight of the evidence regarding program outcomes Schroeder, J.A (2011). Integrating implementation science, practice and policy. National Implementation Research Network 12. Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F(2005). Implementation Research: A Synthesis of the Literature. National Implementation Research Network

22 Where have we come from? Pharmaceutical Care: Hepler & Strand s seminal model Expanded role: Demonstrating the value of the pharmacists Barriers: time, money, education, attitudes Practice models: shift from retailing to cognitive services PCNE initiates Asthma TOM and OMA studies Compliance: Legislating pharmaceutical care Making the case for payment: remuneration of pharmaceutical care services From policy to practice: Implementation focus at all levels How to : the process for provision of pharmaceutical care Individual behaviour change approach: Skills, motivation, education Organisational approach: applying change management theories and concepts No magic bullet: Identification of facilitators and their complexity No one size fits all : Focus on flexibility and capacity building Pharmacists in primary healthcare: collaboration, quality, evaluation

23 Where are we now? Pharmaceutical Care: Hepler & Strand s seminal model Expanded role: Demonstrating the value of the pharmacists Barriers: time, money, education, attitudes Practice models: shift from retailing to cognitive services The implementation gap PCNE initiates Asthma TOM and OMA studies Compliance: Legislating pharmaceutical care Making the case for payment: remuneration of pharmaceutical care services From policy to practice: Implementation focus at all levels How to : the process for provision of pharmaceutical care Individual behaviour change approach: Skills, motivation, education Organisational approach: applying change management theories and concepts No magic bullet: Identification of facilitators and their complexity No one size fits all : Focus on flexibility and capacity building Pharmacists in primary healthcare: collaboration, quality, evaluation

24 The implementation gap In 1999: Pharmacists are being urged to change their practice, but many do not have a clear picture of how the new practice model is to fit into current reality. 13 In 2012: It is still very difficult to implement changes in daily pharmacy practice. 14 And the real gap is for consumers: Individuals cannot benefit from interventions they do not experience Holland, R.W. and C.M. Nimmo, Am J Health Syst Pharm, (17) 14. Bouvy, M.L., Int J Pharm Pract, Schroeder, J.A (2011). Integrating implementation science, practice and policy. National Implementation Research Network

25 What we now know Evidence on effectiveness helps you select what to implement for whom Evidence on these outcomes does not help you implement the program or practice Science to service gap Often what is known is not adopted to help consumers Implementation gap Often no clear pathways to implementation; often what is adopted is not used with fidelity and good effect. What is implemented often disappears with time and staff turnover 16. Mildon, R (2011) Bridge over Troubled Waters: Using implementation science to improve outcomes for children. Presentation to QCOSS Conference 17. Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F(2005). Implementation Research: A Synthesis of the Literature. National Implementation Research Network

26 We also know Successful uptake of knowledge requires 18 : more than one-way communication and one-off training events genuine interaction among researchers, decision makers, and other stakeholders AND active, purposeful and planned implementation activities 18. Mildon, R (2011) Bridge over Troubled Waters: Using implementation science to improve outcomes for children. Presentation to QCOSS Conference

27 Coaching for change Research in pharmacy and other health sectors shows that: Community pharmacies need targeted, on-site support to assist their preparation for change and to build the capacity to integrate new professional programs over time 18 Educational outreach visits appear to improve the care delivered to patients. Trained people visit clinicians where they practice and provide them with information to change how they practice. The information given may include feedback about their performance, or may be based on overcoming obstacles to change Roberts, A., C. Benrimoj, et al. (2007). Community pharmacy: Strategic change management. Sydney, McGraw-Hill. 19. O Brien MA et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2007.

28 At the pharmacy level The need for support to change pharmacy from a product to a product-service orientation is in at least 5 areas 20 : business planning (planning), financial planning (performance), staff management (people and processes), marketing (service awareness), and design layout (infrastructure) 20. Feletto E, et al. (2010) Building capacity to implement cognitive pharmaceutical services: Quantifying the needs of community pharmacies. Res Soc Admin Pharm; 6(3); p

29 Applying this in practice PSA has been running a small trial (n=15 pharmacies) to support pharmacies to adopt a changed model of pharmacy practice in which: the pharmacist is repositioned as a primary healthcare provider; and the pharmacy is positioned as a healthcare destination Not just about just being able to deliver and claim for the 5 th Community Pharmacy Agreement programs Not a one size fits all solution for all pharmacies Focus is on setting the framework for and achieving sustainable delivery of consumer-focused health services Underpinned by evidence on change

30 Foundations for change process Health Destination Pharmacy project kick off 1 day workshop Visit 1 Creating the environment and infrastructure for change Translating the vision into action Visit 2 Visit 3 Monitoring progress Refinement of goals and actions Reviewing pharmacy changes and outcomes Visit 4

31 Program areas

32 What the pharmacists are saying This exercise [participating in the Trial] has made it clear to me what it is I want to be doing, and what I do well. Talking to customers and engaging and educating them on quality use of medicines/disease state management is what makes me tick. Pharmacist, #23 I am really enjoying my practice in pharmacy more than ever. Pharmacist, #14

33 Initial financial results *Financial analysis undertaken by Bruce Annabel, JR Pharmacy Services Indicator Comments Customer and script volumes Script no. growth 3.77% despite official Government data indicating PBS script volumes fell during this period Customer no. growth 1.27%, continuing a similar trend from June quarter. Av health sale $/Rx Up from $10.14 to $13.93 compared to Q Sales Av total retail sale/customer Up from $16.17 in same quarter 2011, to $19.65 Total sales Up strongly for the quarter by $145,011 mostly contributed by health sales increasing by almost $90,000. Gross Dispensary GP$/Rx Total GP$ $14.46 is down compared with prior year likely due to external factors such as Government changes and banner pricing strategy Increased over 12.37% compared with 7.26% up in the June quarter. Health sales contributed almost $54,000 of the $58,000 total store increase. profitability Total health GP% Increased from 39.88% to 45.96%, despite total GP% remaining reasonably steady compared with last year, previous quarter and year ended June 2012 Total retail GP% Reasonably steady compared with last year, previous quarter and year ended June 2012 Wages/sales % Wages reduced despite strong growth in sales so wages/sales % fell to 11.52% from 13.54% last year Staff Wages/GP$ Improved significantly from 39.12% to 32.76% indicating a major productivity improvement GMROL The ultimate staff productivity metric...improved 19.29% from last year.

34 Other participant highlights so far Pharmacy 33 held a diabetes awareness day that involved extensive collaboration with allied health and local GPs. Positive feedback from health professionals involved The pharmacy was full on the day and sold 40 diabetes blood glucose meters Pharmacy 35, after assessing local needs, set up a Baby Health Clinic in conjunction with a nurse and the local GP Pharmacy 12 has built consult rooms for professional services and has rostered a pharmacist onto the floor every day

35 Key messages Early results and should be interpreted with caution Insights so far include Cultural change requires significant focus workflow changes often needed to allow pharmacists to be available for greater engagement Allocating time for planning is critical Setting shared goals and targets for professional services ensures greater chance of success Promoting health image to the community is important for consumer and health professional perception. Owner engagement and whole of team approach is critical

36 Key messages (2) Greater engagement by having the pharmacist available on the floor appears to be yielding results in health sales and GP$. Longer term we expect this to be reflected in customer and script numbers. Regardless of skills or motivation, help is often needed to achieve sustainable changes in practice Understanding and addressing barriers is essential

37 Key messages (3) Regular monitoring of progress required Consider incentives for facilitating change (KPI s) Working with a mentor/coach is a key to achieving goals Professional Practice Pharmacist career path

38 In Australia today Drivers of innovation/change: Current and future viability concerns due to competitive pressures and Government reforms are pushing pharmacies to search for other opportunities Current health reform agenda in primary care is supportive a shift to more patient-focused services There is increasing evidence of positive outcomes - including financial - for pharmacies moving away from the status quo

39 The Community Pharmacy Barometer TM We need to move away from price A biannual measure of community and head towards pharmacy service, confidence especially which aims to: fee for service where we stop being provide the profession, pharmaceutical industry and other stakeholders dependent on the government for with independent qualitative revenue. and quantitative This will also make research the on the perceptions, attitudes, knowledge, experiences industry more and professional behaviours and of less community pharmacists as they relate to the retail future orientated professional practice and business of community pharmacy. 21 The first report (April 2012) showed an overwhelming majority of pharmacists see service orientation as the key opportunity. The second report (Oct 2012) documented a strong trend to service provision by community pharmacy: 81% of pharmacists surveyed were currently offering or have offered 5CPA services 30% reported that they were extremely likely to adopt services created by pharmaceutical companies. 21. University of Technology Sydney and Cegedim Strategic Data (2012).

40 Funding models are important Implementation scientists suggests that a four-point approach to funding be developed to support implementation of evidence-based programs, including 22 : 1. Start-up costs (e.g. Equipment, infrastructure) 2. Purveyor support (e.g. forums, assessments, organisational change) 3. Funding for the service itself 4. Ongoing support of infrastructure for sustainability 22. Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F(2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network

41 Research findings Policy makers in pharmacy have a key role in supporting community pharmacies to implement services, which must be part of a greater strategic plan or change management strategy Each service must have an implementation strategy that includes individual and organisational level facilitators. Community pharmacies need targeted, on-site support to assist their preparation for change and to build the capacity to integrate new professional programs over time. 23.Roberts AS, et al P (2008) Practice change in community pharmacy: quantification of facilitators. Annals of Pharmacotherapy- 42 pp Roberts, A., C. Benrimoj, et al. (2007). Community pharmacy: Strategic change management. Sydney, McGraw-Hill.

42 These things cost money! 1. Start-up costs (e.g. Equipment, infrastructure) 2. Purveyor support (e.g. forums, assessments, organisational change) 3. Funding for the service itself 4. Ongoing support of infrastructure for sustainability Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F(2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network

43 Why we can t ignore critical implementation factors There is evidence to show that when a program or project requires people to change how they do their jobs, if the change process is not managed it will impact: Speed of adoption How quickly pharmacies will get up and running with the program Not just registration, but actual delivery of services Ultimate utilisation How many pharmacies will ultimately participate in the program And therefore how many consumers receive the service Proficiency How effective pharmacies will be at working in the new way and therefore being able to sustain the service Also ultimately impacting how many consumers receive the service Prosci ww.prosci.com 43

44

45 Funding model As part of the primary care reform process, there is discussion about a shift to performance or outcomesbased funding models Currently most pharmacy services are not funded in this way, and are largely required to provide data to funders on: the effectiveness of the interventions (at an individual level) the adoption rate (at a setting level)

46

47 Outcomes or performance-based funding How would some pharmacy services measure up if asked to report on factors such as: program reach (to individuals) maintenance (both individual and setting)? Would the payers be getting value for money? Half-hearted or ill-advised attempts to implement welldefined practices and programs are a waste of time and resources and may further frustrate and disillusion human service consumers, providers, and system managers Fixsen DL, Naoom SF, Blase KA, Friedman RM & Wallace F(2005). Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network

48 Where to from here? Emerging research applying an implementation science approach Defining the range of professional pharmacy services within a model of pharmacy service provision 26 Developing a professional services index to quantify rate and depth of implementation and service provision 27 Ultimately allowing community pharmacy to be differentiated and recognised as providers of professional pharmacy services 26. Moullin JC, Sabater-Hernández, Benrimoj SI (2012). Professional Service Implementation Index [Poster] FIP Congress, Amsterdam 27. Moullin JC, Sabater-Hernández, Benrimoj SI (2013). Defining professional pharmacy services the role of community pharmacy [Poster] PCNE Workshop, Berlin

49 Conclusion One of our great successes has been achieving funding for a range of services delivered by pharmacists As funders around the world increasingly shift towards outcomes or performance-based remuneration models, we can no longer accept poor program implementation or future funding will be at risk We all have responsibility for addressing this; there are implications for researchers, policy makers and practitioners

50 Implications Researchers Dissemination and implementation research must be prioritised in order to bridge the implementation gap. Individuals cannot benefit from interventions they do not experience 28 Policy makers Remuneration and implementation models must reflect the evidence about how successful change occurs. Practitioners Must be supported to make changes to their businesses that facilitate sustainable delivery of services. 28. Schroeder, J.A (2011). Integrating implementation science, practice and policy. National Implementation Research Network